If you have been reading my crap information on second MTP synovitis you already have a good idea where I am going with this.
I have one correction, actually an omission, regarding Part 1. In Part 1 I talked about the notion that the 2nd metatarsal has grown “too long.” Here is another knee slapper, actually even more ridiculous; being told your 2nd metatarsal has “dropped.” Seriously, DROPPED? These two long held reasons, actually myths, for problems related to the 2nd metatarsal, plantar callosities and second MTP synovitis, are short sighted and demonstrate a total lack of biomechanical understanding. To quote my favorite online quip from the Musings of a Dinosaur, Rule number 10, “A bad idea held by many people for a long time is still an bad idea.”
Law 10: A bad idea held by many people for a long time is still an bad idea
So let’s just get this straight for the sake of a crystal clear understanding, the 2nd metatarsal does not change in time. It does not grow longer and it does not drop, period.
The isolated gastrocnemius contracture is the underlying problem, and the only underlying problem, causing second MTP synovitis, which eventually leads to 2nd hammertoe and more eventually to a 2nd MTP joint dislocation. BOOM! Another scoop, I called it! I know what you are thinking and before you get going, hear me out.
So, let’s take this on step by step. As we age, the majority of us experience a gradual tightening of our calves: the isolated gastrocnemius contracture. It is almost always unnoticeable, so you are unaware it is there or that it is causing a problem. Over time the isolated gastrocnemius contracture will do cumulative harm to your foot and ankle in many areas and ways. Because of this calf tightness, the amount of pressure born on the front of your foot, the metatarsal heads or ball of your foot, increases.
All the while our forefoot anatomy has not changed, such as the magical growing or dropped 2nd metatarsal. The statement “Your 2nd metatarsal has dropped” has always cracked me up and at the same time gotten a lot of patients in trouble. The 2nd metatarsal has not changed one bit. It is well known to be the longest and the stiffest metatarsal (due to the “Keystone effect”) of the five in the great majority of humans. We were born this way and this anatomy does not change. The only thing that has changed is the isolated gastrocnemius contracture creeping up on us.
So, if there is going to be more pressure born to the metatarsal region because of the isolated gastrocnemius contracture it will be focused on the 2nd metatarsal head because of our natural anatomy. Step after step the pressure focused on this one poor innocent bystander, the 2nd metatarsal head, creates damage to the second MTP joint. You could say the 2nd MT is a victim of circumstances.
Then comes the pain and usually swelling along with the painful ball or lump feeling on the bottom of the foot. BTW, one will never experience actual swelling with a Morton’s neuroma. A kissing cousin, a metatarsal stress fracture, far and away most commonly of the 2nd metatarsal (any guesses why the 2nd is most common? Hint: it is not a “dropped” 2nd metatarsal) is characteristically pain and swelling is exclusively on the top of the foot.
But I digress. The 2nd MTP joint capsule and synovium (joint lining whose purpose is to make joint fluid providing nutrients for the cartilage) becomes angry and inflamed trying to solve the problem of the repetitive trauma and there is excessive joint fluid produced. This is exactly what our bodies are supposed to do when stressed in this manner. This is the inflammatory response and is a good thing unless the underlying mechanical problem is not corrected, then it becomes a chronic inflammation.
The joint becomes distended much like blowing up a balloon and as a result the structural support system becomes stretched out. This includes the collateral ligaments and the plantar plate. Left unattended, voilà, you have a hammer toe. Wait longer and you will get to experience that mysterious dislocation syndrome.
Just in case you need additional help with this concept watch my animation of how you get an acquired second hammer toe:
This is not trauma, or some random mysterious inflammation, or a only plantar plate rupture, and it is definitely not a dropped second metatarsal. You can’t avoid getting older, but you can treat this problem in development and better yet you can prevent the second crucial step by stretching your calves. It’s your choice, symptomatically treat your foot or fix the problem and stretch your calves.
Stay healthy my friends,
AO
Hi
I agree that increasing forefoot ground reaction forces are common as normal part of aging, sedentary lifestyle and disease process such as DM and that this is likely largely a function of increase ankle joint complex stiffness attributed to loss of triceps surae flexibility. I agree that in most of population forefoot pressures are highest at 2nd metatarsal head during walking and running gait. I agree that there is a tenancy for surgeons to look in their “surgical options” tool box and that there is concern that the toolbox is largely filled with manufacturers product. All worthy Stuff. I disagree with your premise that metatarsalgia is most commonly explained by synovitis. In our clinic we use sonography as an extension to our physical exam in recalcitrant metatarsalgia and finding of synovitis is extremely rare based on lack of finding signal with power Doppler imaging within synovial envelope. If you are unfamiliar with this metric look at the abundant rheumatology medical literature which shows sonography as a highly sensitive and specific for detecting inflammatory joint disease. I applaud your rant against mindless use of surgical procedures, common concern regarding poor diagnosis of cause of metatarsalgia and would enjoy discussing the empirical findings of our clinical approach around metatarsalgia further if you email me.
Thanks for contacting me and your kind words. It is really great to see that more people are “getting it” like you obviously do. I tend to be very old school and believe in history and physical and it has served me well. I tend to not do diagnostic studies such as ultrasound or MRI for these issues only because they are easily diagnosed by old school and the expense especially in the U.S. I do not doubt these studies as an adjunct, just not for me on a routine basis. As far as “synovitis” is concerned I would say that is what I believe it to be and what I call it(because that is what it is). However, regardless of what it is or what it is called, synovitis, capsulitis, plantar plate rupture, etc. the diagnosis is very common and consistent by history and exam. And it responds on a very high percentage (97%+) to calf stretching as definitive treatment, along with orthotics and cortisone injections in 2nd MTP, etc. for symptomatic treatment while the calf stretching does the real work, albeit slowly. I am glad to discuss things.
As a side note, I trained for 6 months at St. Barts in London as a Sr. Registrar in the mid 80’s. I loved it every bit and loved England.
Best regards,
AO
I have been diagnosed with predislocation syndrome and will be getting an operation for it in 2 days . I do not have hammer toe and have never been told I do. I also stretch my calves regularly and have been stretching for years. Insoles never help and I wear wide toe box shoes. I have also tried taping, ice and anti-inflammatory. Nothing has helped. I think the calve stretching is really just another guess.
Best of luck with your surgery. I really hope it helps your problem and I bet it will. For the benefit of everyone out there, you bring up a very good point. I am not saying calf stretching is the solution for everyone, but I will say it is definitely not a “guess” and it is the solution for well over 90% (97% in my unpublished experience). The core problem is still, and always has been the isolated gastrocnemius contracture and if left unattended will go on to create more problems in your foot and ankle. Your comments and experience of N=1 shouldn’t sway others to not stretch.
My experience of N=1000 plus says otherwise. As a final note I can’t tell you how many times I have heard “I have tried everything” or “I have stretched for years”, only to see people move on to resolve their problem, whether it be second MTP synovitis, insertional Achilles tendinosis, etc. stretching using my protocol. Without surgery.
Stay healthy my friends,
AO
Basically predislocation syndrome is caused by excessive pressure on the base of that toe, a bunion under-riding the second toe, or perhaps even a short first ray.
My reply is not meant to personally offend, but you teed up the ball and I must smack it with my driver. The mere fact that you are using the term “predislocation syndrome” is concerning. OK, these are interesting concepts and exactly the dogma that leads my colleagues down the wrong path, the path of certain surgery. No doubt that each of these physical factors contribute in a minor way. Consider this, if transfer metatarsalgia (how a bunion transfers pressure from the first to the second MT head, not crossing over or under the second toe) and/or a short first ray are the primary forces we should consider, then basically ONLY surgery can solve the problem. These two problems cannot be resolved/correct without surgery. This is indeed a convenient point of view for a surgeon to present to a patient. In addition, these deformities are most often present for years, paricualarly an incompitent, short first ray present from birth. Why second MTP synovitis now, why not last year or 6 years ago. The anatomy has not changed, but something has changed: equinus.
Stay healthy my friends,
AO
My reply is not meant to personally offend, but you teed up the ball and I must smack it with my driver. The mere fact that you are using the term “predislocation syndrome” is concerning. OK, these are interesting concepts and exactly the dogma that leads my colleagues down the wrong path, the path of certain surgery. No doubt that each of these physical factors contribute in a minor way. Consider this, if transfer metatarsalgia (how a bunion transfers pressure from the first to the second MT head, not crossing over or under the second toe) and/or a short first ray are the primary forces we should consider, then basically ONLY surgery can solve the problem. These two problems cannot be resolved/correct without surgery. This is indeed a convenient point of view for a surgeon to present to a patient. In addition, these deformities are most often present for years, particularly an incompetent, short first ray present from birth. Why second MTP synovitis now, why not last year or 6 years ago. The anatomy has not changed, but something has changed: equinus.
Stay healthy my friends,
AO
I’d like your instructions for stretching my calf. I’ve been in pain for well over 2 1/2 years!! I was diagnosed, taped/iced, prednisoned, $500+ orthotics in my tennis shoes (which is all I wear now–lovely with my dresses for school–I’m a teacher) and am looking online for info to make that decision for surgery. I do a lot of photography, and go down on a knee, bending that “bad” toe often. Basically, I was told, “When you get tired of living with it, have the surgery.” NEVER have I been told to “stretch your calf”. I’ll try that, too, if you don’t think it is too late (I still think that this all started when I stubbed my toe!) I am 64, and presented with severe pain in the pad of my foot with every step I took. At least with the orthotic, I CAN walk!
Jo, Jo, Jo.
It is never too late for almost everything orthopaedic. Are you referring to your big toe or the second toe right next to it? I think you are referring to the second toe and second MTP synovitis. If so, calf stretching will almost always work if done correctly and long enough. Actually, if you are referring to the big toe then the problem is likely hallux rigidus and stretching helps that too.
The advice to keep going until tired of living with it is correct if one feels there are no good options left except for surgery. How convenient! But there are mitigating, actually curative, options short of surgery as long as the root cause (equinus, calf too tight) is known and believed. One of the two reasons is exactly why your surgeon will not recommend calf stretching. They either are ignorant of the abundant evidence or they know something, but they don’t believe. After all, we are surgeons just like the scorpion ferrying the river on the frogs back. When you are a hammer everything looks like a nail. Okay, I think you get it. Surgeons cut. Here’s a thought, maybe better to treat patients.
So, definitely stretch! I have instructed/coached many, actually about 90%, patients out of the throes of surgery and back into action with just stretching calves. Of course, simultaneous symptomatic treatment is often needed. These would include cushioned shoes, metatarsal pads, NSAID’s, and even a cortisone shot in the joint. But please don’t forget to correct the calf.
All I can say is other than lip service the medical world has no interest in calf stretching as a definitive treatment for much of anything. Pity, because it works.
Stay healthy my friends,
AO
AO!
Through too much barefoot walking and an overstretch of my toes i started feeling pain on the bottom of my foot.I have had bruising feeling directly under the ball of my foot on the 2nd meta for about three months. I a m a very active runner. Took a lot of time off. iced a ton-no running etc. still felt it. Got an Mri, doc says plantar plate sprain and tenosynovitus. 8 weeks no running, several weeks in a boot icing taping therapies. started some walk running and still feel some bruising sensation although it’s not as severe or consistent. Have done a lot of calf stretching as well. Anything I am missing? Does the synovitus need more time? Will it go away even If i go back to running? Would love any insight
Hi Will,
Here is my insight! Interesting question and you follow the classic though process, “I doubt calf stretching has much to do with all this or will work” comment. It might appear you made me angry, but not true. The source of your question, others continuing to remain ignorant, makes me angry and as a result I am going to pick apart your query. I am killing the messenger because I actually want you to get well and run pain free again.
Right off the bat you state the cause of your problem as too much barefoot walking and over stretching toes. I would say at most these things are coincidental or at most the straw that broke the camel’s back, but not the cause. If this was true don’t walk barefoot anymore and leave your toes alone and all will be well, right? Then you mention all the other things-ice, time off, MRI, boot, taping, etc.- that might make you feel better, but do nothing to address the underlying cause, the equinus. Palliative treatments are helpful, but they fail to address the real problem.
Then finally there is a sort of off the cuff mention of calf stretching. I actually get it, but that is why the post is there.
Calf stretching is no doubt a hard habit to keep up with and it takes time, often months, but it works most of the time (90% plus). Granted calf stretching does fail, even when done my way. However the majority of “failures” are a failure of doing it and who would actually admit that-not me. Sorry, but this is true. Everyone is so happy to point out, “see, I told you it would not work”. This is a self-fulfilling prophecy I would say. As much time as I put into making sure my patients understand and will carry thru with calf stretching, the great majority of those who eagerly point out it failed admit they did not do it or did it in a limited manner. Why? Because they were certain it was destined to fail because it was not powerful enough medicine. I often hear comments like, “OK, stretching may be good for someone else, but I have a real problem that requires real treatment, not just calf stretching”. Calf stretching is real treatment that almost always works provided one does it and does it correctly. Please read the blog again as I am sure I included all of this.
One additional note is cortisone injections in the 2nd MTP joint can be very helpful as one continues calf stretching. This is especially true if there is swelling at all.
I feel better already. Thanks for the venting session.
Stay healthy my friends,
AO
Hello! Thank you so much for your posts! Similar to other comments, I was just diagnosed with “Predislocation.” I have had a feeling of “fullness” at the base of my three middle toes along with swelling of those three toes for about a year. I have been through orthotics, PT, tons of foot strengthening exercises, etc…. Yesterday, I was given a cortisone shot (first of my life as I have put those off as long as possible) and a weird apparatus that holds my middle toe in place with a pad under the ball of my foot. I have been told not to jump, run, put pressure on my toes such as when doing lunches. I was not told to stretch my calf as he said my calf was very limber. However, I don’t think it is limber enough. Can you suggest some specific calf stretches I should be doing? Also, should I be icing or applying heat? Are foot massages good or bad? I don’t want surgery!!! I want to heal and I will take the time and effort to do it.
Thank you! Erica
Hi there Erica,
Sounds like you got it, girl. Better, you have the right attitude! Here is the sad thing, measuring the ankle and thus calf flexibility, the Silferskiold test, is unreliable. Just because the herd tests for equinus it does not make it right or correct. In fact, it is a waste of time. Follow me here! It is clear there are those with significant, Silferskiold test positive, equinus and have no symptoms or have problems related to the equinus. OK, this one is easy that most can understand. Then there are the many patients who carry a diagnosis that can ONLY be a result of equinus, yet they demonstrate a negative Silferskiold test, meaning no equinus, right? The knee-jerk assumption is that the problem is not due to or related to equinus and it never gets treated as a result. Oh, but it is related. I can’t tell you how many patients when I too did the Silferskiold test (before I realized the lack of utility of this test) who tested negative (no equinus) who stretched themselves right back to health and regained quality of life. And like you this was after EVERYTHING had failed to work. I am getting worked up here and it feels so good.
Finally, for second MTP synovitis, intraarticular cortisone shots can be very helpful and prevent the ultimate hammertoe formation.
Stay healthy my friends,
AO
I’m not sure who’s more pissed off, me or you. I have Morton’s Foot and high arches. Had a year and a half long PF battle 15 years ago. Recently, started the dreaded second MTP pain with callus. Haven’t run, walked or hiked much since March. Pain is mostly better but second toe has migrated off center and is beating on the side of first toe in an attempt to climb up on top, I assume. MRI shows angry joint and a diagnosis of Capsulitis of the Second Toe. Been taping and stretching but clearly not long enough. Found your angry self this morning and just did my first round of AO stretches. I’m a little OCD so will no doubt do this every day from now on. My question, finally, will my toe return home assuming I haven’t torn my plantar plate? I need hope!
Mike, Mike, Mike,
How dare you assume you could be more pissed than the AO. That makes me angry. OK, I am calming down now with some deep breathing. I agree, it sounds like second MTP synovitis. Not to be a downer, but high arch feet may slightly decrease the odds of calf stretching success due to the angle of inclination of the metatarsals, which creates even more focused pressure on the second metatarsal head. But consider this, you have had a high arch foot most if not all your life, so why second MTP synovitis now? What has changed? The change is the development of equinus.
This will sound like bad news, but your toe will not return home, but in most cases, it does not need to return home. There are only two potential factors that can result in pain, and these must be differentiated. First and most important is the pain produced by the second MTP synovitis. The pain is not coming from the crooked toe, so resist advanced measures to control it, like surgery. Of course, if the crooked toe rubs the adjacent toe or the shoe then it can be the source of pain. But, that is a different pain altogether. I guess I am saying don’t confuse one for the other. I have had plenty of patients thru the years with your exact story, but unlike you, they are convinced the problem is the crooked toe and nothing else. They present insisting on having the toe straightened. Talking about your low hanging fruit! After extensive mind-bending convincing I talk them out of surgery losing revenue for myself, I get them to stretch, and voilà, a few months later they have a painless foot with a crooked toe. So. keep taping the toe as well as occasionally over manipulating it in the opposite direction it is heading. And stretch your calves.
Stay healthy my friends,
AO
Pissed off about the crooked toe but will follow your advice and look forward to walking pain free! Thanks for responding!
Mike,
I will say again and I have no way of knowing for sure in your case, but the synovitis pain is the problem and the crooked toe is what you see and thus link together as one. I hope for your sake that I am right when I say that someday you might look down after a long, painless run (or other activity you can’t do now) and see a crooked toe and you don’t care. If the crooked toe is really a problem all by itself, then surgery might be an option. Best of luck.
Stay healthy my friends,
AO
Thank you for the information. I have been desperately searching for an alternative to the surgery recommended to me. Do you see patients? I have not been able to find any office information.
Thank you!
Hi Annie,
I am afraid I am anonymous here. Please read thru the site and see if you can find help here.
Stay healthy my friends,
AO
I have had this issue for a yr and a half. Excacerbayed w walking a lot of golf rounds. I’m 43yr old male. Active. Collegiate lacrosse. Barefoot running in my thirties… never an issue. Then 40s…job n fam dominate… little to no stretching. Pain level post golf not debilitating just a chronic nag for a few days.
Wasn’t getting better… have all the cardinal signs: callous right under, very slight hammer toe, unnoticeable except after much google education. 2nd toe can be displaced dorsally wo pain… just some instability, diagnosed as plantar plTe year mpj dislocation. Surgery recommended. This was feb 2018…and I couldn’t be seen til may where I live (lot of diabetes / foot amps I guess) and I didn’t want to mess up spring summer activities like golf… so all summer I just carted (golf) and took it easy on it. Even did a four day hike around mt hood (10 mi/day w a lot of vertical) w 40 lbs on my back. Feet sore but not that joint. Just wore stiff soles. So now it’s nov and I am scheduled for this surgery on 20th… and after reading this article and taking to another orthopod I know I am heavily leaning towards NOT doing this surgery and stretching heck out of my calves and maybe getting some metatarsal pad / stiffer insoles…
Thanks for helping me make a decision. My toe may displace upward for the rest of my life when manipulated but who cares so long as it doesn’t hurt and I understand the mechanism and how to best affect / limit the strsss on that area.
Bill
Hey Bill,
My youngest got married on Mt. Hood. Wonderful place as is Portland. I really can’t add to your insight except for two things. First, what the heck do you have to lose by stretching, which will likely help you in more ways than you currently know. I think you will be amazed. The “crooked toe” will be there, but as you alluded to it is not the problem. Second, I have a short story. A primary care doc I knew fairly well years ago was an accomplished triathlete for his age. He saw me for a second hammertoe (and dislocated 2nd MTP) and pain. He wanted nothing to do with surgery, hence one of the reasons he saw me. We know it was not for my pleasant, calm personality. When I explained the source of the pain he got it just like you and started stretching. I have not seen him in a while, but I saw him off and on in and around the hospital for the next 20 years and I would without fail ask him, “You know I am a talented surgeon, I could fix that thing for you.” Of course it was our joke because he continued to rule in the triathlete world. Don’t fix a toe, fix the person!
Stay healthy my friends,
AO
I’m going through this issue now – glad I found this post.
I’m curious – what are your thoughts on cortisone injections and how do they help?
I’ve read conflicting information. Some day to always avoid it in the foot, others say to get it done. I will follow ice, tape and stretching, but a bit curious on the injection.
Would love to get your opinion!!
PS. I have this issue, and in total agreement about calves. Podiatrist put me in orthotics that raised my heel 2 inches off the ground. Tightened my achilles, and calves. Horrible pain. Got it sorted out with PT. Months later, I get home from running with plantar fascitiis. 1 month later, MRI, and I have a plantar sprain. All because of those wrong orthotics.
Hey Rick,
I love the part about wrong orthotics and your observation of the heel elevation. Dead on brother. But I must have a short rant on orthotics. Orthotics, while they can make one feel better in many ways, they do not biomechanically change a thing. And there is no supporting evidence for the use of orthotics for plantar fasciitis. It is a placebo effect, period…..but they are sexy. On the other hand calf stretching enjoys plenty of evidence, but unfortunately not sexy.
As to cortisone injections, they definitely get a bad rap. Technically, cortisone stabilizes membranes and as a result, it is a fantastic ’steroidal’ anti-inflammatory. When cortisone is injected strategically with a confirmed diagnosis in the correct anatomical location it can do wonders. However, from an orthopaedic perspective, a cortisone injection fixes nothing. In most cases, it will make you feel better, way better, which is perfectly warranted for short term help. However, the mechanical source of the inflammation, the root cause must also be addressed, not just the inflammation. Case in point, plantar fasciitis. Granted plantar fasciitis is most often self-limited, but too many people have had too many injections while the equinus is not addressed. Get the injection to help it today and calf stretch to get rid of it tomorrow!
The two genearl mistakes I see with cortisone injections are one, point injections injected in a point tender area. Diagnosis would be helpful, right? The second is strategic injection while the root cause is ignored. Just keep on injecting. As I said, cortisone injections don’t FIX anything.
Stay healthy my friends,
AO
Hi AO,
Thanks for the response!!! Very much appreciate it. I just read your comment on another post and wanted to follow up with a question. Your wife sounds just like me – although I have stayed away from any type of cortisone injection as I am afraid to make things worse and cause more damage. Your explanation above makes me feel a bit better about getting it done.
My question is; where were you injecting the cortisone for your wife’s issue? Directly into the plate? I’m just curious because I believe I will be getting an injection soon and want to ensure my doc knows what he is doing and he injects it in the right location. 😉 I’ve heard about ultrasound injections as well.
Additionally, did your wife do anything else besides the stretching? Metatarsal pads? Different shoes? Taping? Ice? Contrast therapy?
Overall, my plantar fasciitis is completely gone, but I still have a pebble sensation in my 3rd mtp where it showed I had a plantar preformation in my MRI. It’s not painful, just a little sore if I really really rub it hard. I also get a crackling sound when I push off my forefoot if I’ve sat for a long time.
Anyway, thanks for the responses! Your blog has been really helpful for me. I’ve been actively stretching every day
Ricky,
You have done fired me up boy. Injecting an MTP joint is about the easiest thing to do and if someone needs an ultrasound that only means one of two things: gross inexperience or more likely a money grab. Medicine has turned much into, “We have this technology, so let’s use it”. Even though it adds no benefit. Don’t get me wrong, there are many areas where technology is clearly a great benefit to efficacy and safety, just not here. The inject needs to go into the MTP joint as it did not my wife’s joints and hundreds of my patient. The plantar plate issues arise from joint swelling which results from synovitis, for god’s sake just watch the video.
So, the third paragraph kind of got you out of the dog house. She did have a met pad. She also wore more padded comfy shoes to cut down on the met head on the hard surface effect. Ice and contrast Rx would be Ok, but only when pain requires it. Keep in mind this is MECHANICAL and these other things are just for temporary relief. I know this is not for you, but the mechanical cause is all too often discounted or whatever other reason, but everyone must keep their eye on the ball. It is all about the long game, not the short term vacations from pain. That was pretty damn good, huh?
Finally, I don’t put a lot of stock in an MRI except where indicated and judiciously at that. There is sort of a rule in medicine that we should already basically know the diagnosis based almost entirely by patient history, supported by physical exam and finally confirmed by a test such as an MRI if needed. Where is the fun in just ordering a test, which is done all too often and an increasing trend by the moment.
Ask your doc the location/target as to where the injection is intended. That is fair to ask, it is your foot after all. This brings up a final question, “Why would a doc not inject the joint in favor of injecting a web space, or post injection (inject the point of tenderness) or anything other than the MTP joint in this situation.” The answer is simple, they don’t understand the pathophysiology. As I stated in my blog on second MTP synovitis the plantar plate tears are not magic and they are not the focus…until it is too late.
Stay healthy my friends,
AO